Latest / Intellectual Medicine / Vitality After Prostate Treatment: Reclaiming Confidence and Connection

Transcript

Vitality After Prostate Treatment: Reclaiming Confidence and Connection · Intellectual Medicine

• 0:00
  No matter where you are in the continuum of prostate cancer,
• 0:06
  it's treatment or the contemplation thereof, I want
• 0:09
  you to never give up. Never give up on vitality.
• 0:13
  Never give up on living a full, healthy life.
• 0:17
  My goal for everybody in my practice and for you all
• 0:20
  listening is a horizontal lifespan.
• 0:23
  Feeling great, feeling great, feeling great, and then dying
• 0:26
  quickly. Kind of sad to think about death
• 0:28
  existentially, but we know it's out there.
• 0:31
  What most men, what most people fear is the infirmity and the
• 0:36
  withering. So we're talking now about all
• 0:41
  aspects of vitality, mind, body, spirit, sexual health in
• 0:45
  particular. Now for those of you that have
• 0:48
  already had treatment for the prostate, perhaps the Glen was
• 0:52
  removed, maybe radiation, maybe you had some other type of
• 0:57
  localized destructive cryotherapy, haifu, etcetera.
• 1:02
  They all have a negative impact, potential adverse effect on
• 1:07
  sexuality. Men will tell me I don't feel
• 1:11
  the same, something has changed. So the goal is to adapt to the
• 1:17
  change at the same time trying to overcome it.
• 1:20
  And there are things you can do regardless of where you are.
• 1:24
  So I'm going to focus in particular on those of you that
• 1:26
  have already had treatment with surgery or radiation.
• 1:30
  Now you know that I am very skeptical about its value.
• 1:34
  However, I respect the fact that there is no clarity of pathway
• 1:39
  forward and that many men will choose to get a prostatectomy or
• 1:45
  have radiation therapy. It's not the wrong decision as
• 1:49
  long as you make it with open eyes and with good information
• 1:55
  all the way around, including absence of fear and urgency.
• 2:01
  All right, So what can you do to maintain sexual vitality?
• 2:07
  The first part of that is expect to maintain sexual vitality with
• 2:13
  or without erectile function. Of course, you'd prefer to
• 2:17
  maintain erectile function. So things that men have done and
• 2:20
  some of the research can support this.
• 2:22
  In the preoperative phase, men who were started on daily
• 2:26
  tadalafil or Cialis. Now in the studies they did 5
• 2:29
  milligrams. But in practical treatment, most
• 2:33
  of the clinicians that are practicing andrology or
• 2:36
  testosterone therapy looking at 20 milligrams a day started
• 2:41
  preoperatively and continued postoperatively seem to
• 2:45
  correlate with better outcome regarding erectile vitality and
• 2:50
  tadalafil and the other PDE 5 drugs like Viagra, etcetera.
• 2:56
  They don't have any negative effect on the prostate cancer
• 2:59
  itself. So they're safe to use so long
• 3:01
  as your doctor agrees. Make sure that you're getting
• 3:04
  monitored carefully. So that's an important
• 3:07
  preoperative endeavor or pretreatment.
• 3:11
  If you're struggling with erections, how about afterward?
• 3:14
  Now, afterward, if you've had surgery and you're struggling
• 3:18
  with your erection, it can still be revitalized.
• 3:21
  I advocate the use of a vacuum. It can be used at the time of
• 3:27
  sex, so the vacuum can help negative pressure and gorges the
• 3:31
  penis. You can use a ring at the base,
• 3:34
  and now there's some erectile quality.
• 3:37
  However, it can also be used as part of penile rehabilitation.
• 3:42
  So postoperatively, you want to keep that penis engorged.
• 3:46
  You do not want us to suffer disuse atrophy.
• 3:50
  And even when you're not sexually energized, the libido
• 3:54
  is down, you still want to keep the anatomy healthy.
• 3:57
  So I advocate the use of a pump as soon as you can, even if it's
• 4:02
  been months or years, because there are cases of delayed
• 4:06
  recovery. So getting the tissue to stay
• 4:10
  healthy, that's an important detail.
• 4:13
  The PDE drugs can be of some value, although in many cases
• 4:18
  they're just not sufficient. So we've got an anatomical
• 4:22
  problem. There's been disruption of the
• 4:24
  nerve and the blood supply. Maybe the erections are just not
• 4:29
  functioning, perhaps they never will.
• 4:33
  We talked before about the value of physical intimacy.
• 4:37
  Your loved one wants to feel your touch, whether or not
• 4:43
  you're getting an erection. Do not deprive each other of
• 4:46
  touch comfort. There are no real supplements
• 4:50
  that I could recommend that in that are good unto themselves,
• 4:54
  but there are some used in complement with these drugs.
• 4:57
  L citrulline, in particular. L citrulline is a supplement
• 5:02
  that is a precursor to nitric oxide.
• 5:05
  Nitric oxide helps vasodilate. L citrulline is sometimes
• 5:10
  described as a supplement. Alternative or complement is a
• 5:14
  better way to think of it to drugs like sildenafil.
• 5:18
  You could take doses of 2000 up to 6000.
• 5:22
  It's also used for folks going to the gym.
• 5:25
  I take a dose before I hit the gym every morning.
• 5:27
  Vasodilates get a little bit better muscle pump, so it could
• 5:31
  also help at times of sexual activity.
• 5:34
  Couple hours beforehand when you're really stuck and you want
• 5:39
  to revitalize the erection, the Trimix or alprostedol, another
• 5:45
  option. These are injectable treatments.
• 5:48
  Now before you discard the notion, bear in mind the needles
• 5:53
  are tiny. In fact, I'm going to show you
• 5:54
  an example of 1. The alprostedol is also known as
• 5:58
  Caverjet. That's a trade name.
• 6:01
  It's an injectable prescription drug.
• 6:03
  It goes in the base of the penis.
• 6:06
  Think of it as local Viagra. It vasodilates, gives an
• 6:10
  erection. It gives an erection in the
• 6:13
  absence of foreplay, in the absence of sexual desire.
• 6:18
  It is a purely mechanical effect.
• 6:22
  Now, in some cases, feeling the erection happening can enhance
• 6:27
  libido because now there's a degree of confidence you don't
• 6:31
  need foreplay beforehand. You're going into the bedroom
• 6:34
  not hoping you get an erection, but already starting to feel 1.
• 6:38
  So folks, here's the needle. You can barely see it.
• 6:41
  It's about a 31 gauge. These are tuberculin syringes,
• 6:45
  and the needle typically goes into the base of the penis.
• 6:49
  So imagine, there we go, imagine my finger, the needle would go
• 6:53
  into the base right about there. And you do that about 10 minutes
• 6:59
  before sexual activity works very quickly.
• 7:03
  It can be prescribed by your doctor.
• 7:06
  The Alprostedol is a standard prescription drug available at
• 7:10
  most pharmacies. Trimix, on the other hand, is a
• 7:13
  blend of three different vasodilating agents that must be
• 7:18
  compounded for you. The dose can be varied, which is
• 7:22
  advantageous because you can adjust it according to the need.
• 7:26
  So that can restore erectile function.
• 7:30
  But bear in mind erectile function is not the be all, the
• 7:35
  end all, the only means of sexual satisfaction.
• 7:40
  If you have a female partner, she wants clitoral stimulation.
• 7:44
  Men, 15% of women can achieve climax without clitoral
• 7:48
  stimulation with just penetration.
• 7:50
  That means the vast majority need that clitoral stimulation,
• 7:54
  right? So step one, you got to know
• 7:56
  your anatomy, boys got to find out where the clitoris is.
• 8:00
  Sometimes you got to talk to your partner to ask them am I in
• 8:04
  the right spot? Right.
• 8:06
  If you are, then you can achieve a woman can achieve climax.
• 8:10
  And unlike unlike we men, after a woman has achieved climax,
• 8:15
  they remain sexually responsive much more so than men.
• 8:20
  So if you're contemplating in the bedroom, the order of
• 8:23
  activity, woman's climax comes first.
• 8:27
  This is not Hollywood, folks. You're not having a mutual
• 8:29
  climax all the time. That's quite uncommon.
• 8:34
  But if a man has a climax first, usually that's the end of the
• 8:37
  game. And that's not very satisfactory
• 8:40
  to most partners. So bear that in mind.
• 8:42
  It's OK to do things in sequence, so the trimix can help
• 8:47
  with the erections of L citrulline.
• 8:50
  Good play. In fact, in some cases, with the
• 8:53
  guidance of your doc, you can combine these things.
• 8:56
  They can be used together. The greatest risk is extended
• 9:01
  period of time with an erection called a priapism.
• 9:05
  That's pretty uncommon, but it can happen.
• 9:08
  Blood pressure changes on occasion.
• 9:11
  But what about what about the sex drive?
• 9:14
  Now things are disrupted doc, I don't think about sex.
• 9:18
  I have no desire. That's where the non hormonal
• 9:22
  peptides may be of some assistance.
• 9:25
  There is an FDA approved drug called Bremlinotide.
• 9:28
  It's also known as PT141. The PT141 as an FDA approved
• 9:37
  drug. It's approved for female sexual
• 9:40
  arousal disorder. It is an injectable.
• 9:43
  They do have it as a nasal spray, which I do not recommend.
• 9:46
  It just doesn't work that well as an injectable.
• 9:49
  It can be prescribed by the doc at a conventional pharmacy and
• 9:53
  when it's injected it stimulates the part of the brain where sex
• 9:58
  drive lives. So it enhances libido, desire
• 10:02
  and then it supports erection and climax.
• 10:06
  So this can in some cases help to stimulate the lost sex drive
• 10:11
  component that is a missing piece and that can be effective
• 10:17
  in cases of post operative loss of libido or radiation loss.
• 10:24
  How about those of you that may be on androgen deprivation
• 10:28
  therapy? Now you know how much I dislike
• 10:32
  that for you men, how much I am concerned about it being
• 10:36
  utilized too quickly. In particular, if you feel great
• 10:41
  and your PSA is starting to rise, I recommend being very
• 10:46
  cautious before you allow treatment that blocks
• 10:51
  testosterone simply to make the number go down.
• 10:54
  That's a complex reflection unto itself, but take time.
• 10:59
  Get information before you let them castrate you.
• 11:03
  Horrible things happen, but if you're in a circumstance where
• 11:07
  you are at a point that such treatment is in your best
• 11:11
  interest for the sake of symptom control, that's a that's a stage
• 11:15
  at which I would I would support androgen deprivation treatment.
• 11:20
  Bone pain for metastatic disease, right?
• 11:23
  There's a clear indication of potential benefit.
• 11:26
  You can safely use these peptides.
• 11:29
  They don't affect prostate cancer.
• 11:32
  They do have some potential side effects and uncommon cases.
• 11:36
  Low blood pressure, sometimes nausea, but properly monitored
• 11:40
  it's an option to consider. When injected about 6 hours
• 11:44
  before sexual activity. Sex drive increases, libido
• 11:48
  increases, erectile potential can enhance and that can last up
• 11:54
  to 24 hours and the PT141 can be used up to 8 * a month.
• 12:01
  There's another peptide called melanotan which is similar in
• 12:05
  its effect. That drug also has more of a
• 12:09
  skin tanning impact, a little bit less of the sex enhancing
• 12:13
  component. But both of these aging can can
• 12:16
  be used one or the other. Using them in combination is not
• 12:20
  something I'd recommend unless you have an experienced Dr. or
• 12:24
  nurse practitioner guiding you through it.
• 12:27
  So we've got you gentlemen have an ability to restore sexual
• 12:33
  activity by virtue of Trimix oral medications.
• 12:37
  Don't forget the pump for penile rehabilitation and shockwave
• 12:44
  therapy. Low intensity sound wave is an
• 12:48
  FDA approved device. You want to make sure you get
• 12:50
  the right kind of equipment. The Shockwave that I'm talking
• 12:54
  about is an FDA approved device. That's a distinction because
• 12:58
  there are lots of different pieces of equipment out there.
• 13:01
  When applied to the penis, it helps stimulate capillary
• 13:05
  regeneration, new blood vessels, it helps stimulate the
• 13:10
  tumescence, the erectile cells, the hydraulics, if you will.
• 13:15
  It helps those to regenerate. Now, in my experience, I've
• 13:20
  applied this to men at three month intervals.
• 13:23
  I don't think it needs to be stacked really closely together
• 13:27
  because it stimulates regeneration and that takes time
• 13:31
  and it takes several months. And if you do it diligently, my
• 13:35
  experience has been that men tend to acquire, maintain, and
• 13:40
  preserve sexual vitality with better erections over time.
• 13:45
  Things that have not worked that well that you'll read about.
• 13:48
  I've not been that impressed with stem cell injections and
• 13:52
  the corpus cavernosum. They're expensive.
• 13:54
  I think the shockwave is a better play if you're looking at
• 13:57
  regenerative treatments. I've not been that impressed
• 14:01
  with with platelet rich plasma or PRP.
• 14:05
  I think you're better off with Trimix.
• 14:07
  Less expensive, more reliable. So those are a few things that
• 14:12
  you can consider doing what it takes.
• 14:14
  I think most of all is an attitude, a spirit, a desire to
• 14:21
  be creative, a desire to maintain physical sexual
• 14:25
  intimacy, and a willingness to explore some of these
• 14:28
  alternatives. Your urologist may or may not be
• 14:33
  knowledgeable and comfortable with these, but there are docs
• 14:35
  out there who are. Typically they operate in the
• 14:38
  functional medicine space. One of the thing I should
• 14:42
  mention, penile implants. It's an option for those of you
• 14:48
  that are in a good stage of recovery, good medical health.
• 14:52
  It is not an option, generally speaking, for folks who've had
• 14:56
  radiation therapy because there's too much tissue damage.
• 15:00
  One of the many reasons I don't like radiation therapy, besides
• 15:04
  the fact that it doesn't work that great, but it leaves
• 15:07
  lasting lingering delayed tissue damage throughout the area.
• 15:12
  So I've had patients very satisfied with penile implants.
• 15:17
  You must go to somebody highly proficient.
• 15:21
  Go to a surgeon who does this all the time, not a doc who does
• 15:26
  it on occasion. The reservoir is in the scrotum
• 15:29
  so that the hydraulic is in the in the penis itself.
• 15:33
  And when having foreplay, the penis can be gradually inflated
• 15:38
  in a very natural manner. So it's really not as mechanical
• 15:42
  as the old ones used to be, or as it may seem, at least at face
• 15:46
  value. Other things you should
• 15:49
  contemplate that'll help your sex drive and erections.
• 15:52
  Be careful of drugs that you're taking for other reasons.
• 15:56
  Antidepressants are #1 libido and erectile killers.
• 16:02
  Now, sometimes postoperatively or through the course of this,
• 16:05
  depression can occur and drugs like Prozac or like Lexapro or
• 16:11
  others can be can be prescribed. They can add value, but they're
• 16:16
  going to kill in many cases, sex drive and knockout erection.
• 16:21
  They can cause fatigue and they can cause weight gain.
• 16:24
  So as you've become mentally adjusted to your new condition,
• 16:29
  talk to your doc about coming off of these agents.
• 16:32
  I like to do that concurrent with the other libido enhancing
• 16:36
  endeavors. The drugs that can be used
• 16:40
  without disrupting sexual vitality.
• 16:43
  Wellbutrin and Bupropion is 1 to consider, right?
• 16:46
  I mean, losing sexual vitality can be depressing enough.
• 16:50
  Adding a drug that makes that more of an issue is not
• 16:54
  necessarily the best path forward.
• 16:57
  Well, listen, I hope this has been of help to you guys.
• 16:59
  Remember, there's always hope, there's always a path forward.
• 17:03
  There's always a chance at recovery and restoring vitality.
• 17:08
  Keep looking, keep listening, and always stay positive guys.
• 17:12
  We'll talk soon.